Essential Job Functions ESSENTIAL JOB FUNCTIONSPlease put a check mark by each of the following essential job functions that you are able to perform on a repetitive or prolonged basis as a part of your job. Please note by checking that you can perform an essential job function does not necessarily mean you will be required to perform that essential job function on an assignment.Bend(Required) Yes No Sit(Required) Yes No Climb(Required) Yes No Stand(Required) Yes No Crawl(Required) Yes No Stoop(Required) Yes No Drive(Required) Yes No Sweep(Required) Yes No Hand Motion(Required) Yes No Twist(Required) Yes No Hearing(Required) Yes No Walk(Required) Yes No Manipulate Small Parts(Required) Yes No Wrist Motion(Required) Yes No Can you:Work in a confined space?(Required) Yes No Work in a dust or pollen filled environment?(Required) Yes No Work with hazardous chemicals?(Required) Yes No Stand for an 8- or 10-hour shift?(Required) Yes No Work in a hotter than normal environment?(Required) Yes No Work in a colder than normal environment?(Required) Yes No Work outdoors?(Required) Yes No Lift up to 70lbs continuously?(Required) Yes No How much can you lift? 60lbs 50lbs 40lbs 30lbs 20lbs Continuously:How much can you lift? 60lbs 50lbs 40lbs 30lbs 20lbs Occasionally:If you answered no to any of the items above, or if you require an accommodation for anything not listed above, please explain in detail below, any reasonable accommodations you will need.If you checked that you could do all the essential job functions listed above and answered yes to all of the questions above, please initial here:Medical History QuestionnaireDuring employment have you ever had an on-the-job injury that required you to receive medical treatment away from the worksite?(Required) Yes No If yes, please list each injury/incident below.Where employed at the time of injury:(Required)Date of injury:(Required)Nature of injury (i.e., laceration, strain, etc.….)(Required)Other InjuriesHave you ever had any other injuries away from work that currently limit, or will limit in the future, your physical or mental ability to work?(Required) Yes No If yes, please list each and every injury/incident below.Nature of injury/condition:(Required)As a result of your on-the-job or off-the-job injuries/incidents, do you require any reasonable accommodations to perform the work for which you are applying?(Required) Yes No N/A If yes, in accordance with the Americans with Disabilities Act as Amended please give a detailed explanation of any reasonable accommodations that you may require:(Required)These records will be maintained in a strict compliance with HIPPA privacy rules.Signature(Required)Date(Required) MM slash DD slash YYYY Print Name(Required)Email(Required)Last 4 of SSN(Required)
